...“The nursing process is essentially a problem-solving process” (Treas & Wilkinson, 2014, p. 31). It is a standardized way of getting information about the patient to best treat them and then evaluating what you have done. All steps of the nursing process are evident in the electronic health record (EHR), they however are not necessarily next to each other in the order of the nursing process as explained in a nursing textbook. It depends on the format of the EHR that is chosen by your place of employment. “Regardless of the type of documentation that is used, you will use or refer to the nursing process as a guideline when you are charting” (Treas & Wilkinson, 2014, p. 390). There are narrative formats to use when charting in source-orientated...
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...is to examine the electronic health record (EHR) and electronic medical record (EMR) in the home health setting in the United States. “EHR” and “EMR” are often used interchangeably. However, this paper will discuss the differences between an EHR and an EMR. It will cover the benefits and disadvantages of the EMR in the home health setting. This paper will also cover the potential costs associated with the use of the EMR in the home health setting. Finally, the paper will discuss the Technology Acceptance Model (TAM) of an EMR in home health. Outline I. Introduction a. Purpose b. Explanation of terms II. Background a. Home Health Care i. What is it ii. History iii. How it is changing b. Health Informatics in Home Healthcare i. History of informatics in HHC ii. Current use of informatics in HHC iii. Benefits of informatics in HHC III. Comparison of EMR/EHR a. Definitions b. Settings used c. Differences d. Similarities IV. Implementation of the EMR in Home Health a. Feasibility b. Cost c. Equipment d. Staff Acceptance V. Conclusion a. Summary of benefits/disadvantages b. Cost c. Implementation d. Recommendation for implementation for EHR/EMR in Home Health Electronic Health...
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...Nursing: Benefits and Challenges of Electronic Health Records Abstract The Informatics Nurse plays a vital role in training and educating healthcare professionals as they move from paper charting to employing an electronic health record system. According to Zandieh et al., (2008, p. 758) research demonstrates that one of the biggest challenges for moving from paper-based systems to EHR is the perceived skills of staff and their comfort level with a new computer system. The utilization of the Informatics Nurse in the delivery of new EHR initiatives is a critical component in providing a successful outcome for quality nursing care. Nursing: Benefits and Challenges of Electronic Health Records Introduction According to Murphy (2010, p. 283) the Health Information Technology Act in 2009 has required Healthcare systems to implement the conversion of paper documentation to electronic health records. Throughout this process, the need for the role of the Informatics Nursing is growing. Many modalities including, but not limited to, standardizing records and computerizing patient data, all play key roles in the development of best practice. Although EHR, Electronic Health Record, will prove to be extremely beneficial, EHR presents new challenges to the nursing profession. One of these challenges is staff resistance and being able to provide sufficient technical training. This topic is of particular interest because...
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...Introduction Nursing informatics (NI) is the discipline that incorporates nursing science with many data management and systems sciences to ascertain, describe, manage, and communicate data, information, knowledge, and wisdom in nursing practice. Nursing Informatics supports nurses, customers or patients, the Interprofessional healthcare team, and other stakeholders in their decision-making in each role and backgrounds to achieve anticipated results. This support is accomplished through the use of information structures, information methods, and information technology (Healthcare Information and Management Systems Society, 2017). Moreover, Informatics is becoming progressively extant in the nursing vocation due to fast-changing technologic innovations. Healthcare systems are integrating technology into everyday practice at a quick stride. One significant advancement in healthcare technology is an electronic medical record (EMR). “An EMR includes the...
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...Advanced Information Management Western Governors University February 21, 2016 Regulation placed upon the healthcare system only seek to improve safety and security of the patients we care for. The enactment of the Health Insurance Portability and Accountability Act (HIPPA) and the enactment of Meaningful Use Act the United States government has set strict regulations on the security of health information and has allotted for stricter penalties for non-compliance. The advancement of electronic health record (EHR) systems has brought greater fluidity and compliance with healthcare but has also brought greater security risk of protected information. In order to ensure compliance with government standards organizations must adapt technologies such as CPOE and EHR. The use of such technologies also require organizations to develop policies and safeguards to protect both themselves but the community they serve. Team Members and Responsibilities To ensure success in the merger of the health care system, a team of highly trained and competent members will be needed. An implementation manager would be the leader of the team, responsible for keeping the project on schedule, keeping a list of practice issues that need to be resolved, scheduling go live dates, and also be responsible to delegate task to other members of the implementation team. A physician lead is another valuable member of the implementation team. Acting as a liaison between physicians and the implementation...
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...A Case Review of EHR Implementation in a Pediatric Emergency Department Jennifer Juif Southern New Hampshire University A Case Review of EHR Implementation in a Pediatric Emergency Department Organizations face many challenges when implementing an electronic medical record (EHR) system. Quality, safety, and efficiency need to be maintained during implementation. The case study reviewed: Impact of electronic health record implementation on patient flow metrics in a pediatric emergency department (Kennebeck, Timm, Farrell, Sooner, 2012) attempted to quantify the effects of offloading low acuity patients and its impact on length of stay. Length of stay and volume of patients in an emergency department are correlated. The study was conducted in a pediatric emergency department (ER) in Cincinnati, Ohio. Prior to implementation, a plan was utilized to off load patients to a different area in the ER due to a surge from the H1N1 flu virus. This was successful in decreasing patient numbers and length of stay. The organization decided to use the same template for the EHR implementation. Despite its prior success, offloading patients did not improve efficiency or length of stay (LOS) during EHR implementation. The primary issue identified was the failure of offloading patients. The study stated, “During implementation only 5% of patients were diverted. During the H1N1 surge, 10-20% of patients were diverted.” (Kennebeck, Timm, Farrell, Spooner, 2012). The...
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...the Implementation of Electronic Health Record (EHR). The use of health information technology in nursing continues to rise substantially with the sole aim of improving patient care, and outcome while curbing healthcare cost. Bates (2010), noted that the Federal government investment to promote EHR is likely to approach $50 billion. The use of EHR in clinical settings has numerous advantages. Although EHR depicts clinical charting and medical records, its inference is broad, ranging from communication between nurses, quality care, and the research surrounding EHRs that will inform nursing practice in the future (McGonigle & Mastrian, 2015 p.249). Implementing EHR can be very challenging thus, it is important...
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...revolutionizing the healthcare industry by facilitating enhanced care and safety to the patients and potentially saving millions of dollars. The EHR is a longitudinal electronic record of patient health information compiled from all the different encounters that an individual comes upon in various different medical care settings and automates all the data, allowing providers to have all the information in one electronic record. Electronic health records have enormous benefits to offer the healthcare industry, an important one being that they are permanent and cannot be lost; however, it is imperative that all facilities take the time, effort, and resources to incorporate it into their systems. Electronic Health Records: Transforming Today’s Healthcare The electronic health record and the use of clinical informatics have made great strides in improving the quality of care we provide for the population and also saving the industry millions of dollars. “The EHR has the ability to generate a complete record of a clinical patient encounter - as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.” (HIMSS, 2011) Nurses play an important role in helping to facilitate the success of the EHR because they are often at the forefront in the documentation process in many healthcare settings. The EHR uses clinical document architecture (CDA) data standards...
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...Nursing informatics incorporates information technology with nursing science to improve the methods of health care delivery along with documentation. The goal of nursing informatics is to improve documentation accuracy, increase productivity and streamline the accuracy and analysis of clinical data. By integrating the data, nursing informatics facilitates the patient care by providing information and knowledge and support nurses and other providers in their clinical decision making. This can be accomplished by the use of information structure, information process and information technology. Communication is important in today’s complex and integrated healthcare system. As the level of patient care advances, communication continuous to extent across various health care fields and relies on the expertise of health care providers. Therefore accurate documentation is important to keeping all health care providers informed and up-to-date on...
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...Nurse Informatics Shannon S Goff Western Governors University Nursing Assignment The technology necessary to meet the federally mandated requirements which will affect the merged healthcare organizations. Electronic health records with satellite facilities supported by remote technology. Electronic health records emerged as one of the most relevant topics in health care; EHRs are central in the strategy of federal government to transform health care providing in the U.S. (Henricks, 2011). Federal actions are promoting EHR in order to guarantee important implications for nursing practices. The technology implies also payment penalties for those providers who do not manage to meet the requirements of EHRs use. EHR technology has to be certified according to technical and functional criteria that are set forth by the government. The using of EHR technology is significantly important for laboratories (Henricks, 2011) since the certification criteria of EHR have to be related directly to laboratory testing or laboratory management. Federal government identified the goals for improving healthcare and EHRs are central for these goals. EHRs with satellite facilities aims at the following points, it should: * improve safety, efficiency, and quality of public healthcare and reduce people's health disparities; * engage the patients and their families in healthcare services; * improve healthcare coordination; * improve public health and population in general; ...
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...| Nursing Educator | Will evaluate the new system’s usability compared to the old system. Will also be responsible arranging training sessions for all staff. | RN with MSN in Education. Ability to train all staff will make the system change successful | IS manager | Manages the staff that will implement the new system. Must make sure all tech support has proper training | BS in Informatics. Training his staff to effectively help users with technical issues are imperative to system’s success | Chief Nursing Officer | Will be the voice of the nursing staff, bringing concerns to the table. | Determining if the usability of the system from the viewpoint of the nurses (the largest number of users) is imperative. | Chief Medical Officer | Will be the voice of the physicians, bringing concerns to the table. | Determining if the usability of the system from the viewpoint of the doctors is imperative. | Project Committee Interoperability The National Alliance for Health Information Technology defined interoperability as the ability of different information technology systems and software applications to communicate, to exchange data accurately, effectively, and consistently, and to use the information that has been exchanged (Olaronke & Rhoda, 2013) Interoperability is important because it enables medical organizations to operate much more efficiently; it makes it easier for staff to manipulate information quickly; it enhances safety and the quality of care ( What...
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...Electronic Health Records: An Ethical Dilemma Danielle Cooper The University of Texas at Arlington College of Nursing Electronic Health Records The root of current Electronic Health Record (EHR) systems go back to the 1960s and 1970s, when academic medical centers developed systems with the idea of compiling patient health information so that it could be centrally managed and shared (Balestra, 2017). Then, in 1999, the Institute of Medicine published its landmark study of medical errors, to Err is Human: Building a Safer Health System, which stated that health information technology would help reduce medical errors by facilitating transfer of important patient information (Corrigan, Donaldson, & Kohn, 2000). The most...
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...The Institute of Medicine (IOM )focuses on five core competencies for healthcare professionals. In order to provide safe care to patients with the best outcomes, the healthcare system requires an overhaul in order to efficiently take knowledge and implement it into practice. Among the core competencies is the use of healthcare informatics. The IOM (2003) defines utilizing informatics as a way to “communicate, manage knowledge, mitigate error, and support decision making using information technology” (p. 46). By utilizing informatics, healthcare providers can use data to help with decision making. The emphasis on transferring from a paper based healthcare system to a portable, technology based system reduces medical errors, improves patient outcomes, and is more efficient. Informatics involves the transference of data into knowledge that allows the nurse to understand the patient better and make judgments for patient-centered care based upon the understanding of the data. Develop a SMART goal 5 key components make up the SMART goal. First, the specific task is to education nursing staff on the new electronic health record so they are competent users when the EHR goes live. The measurable standard is the bedside nurses who attend the classes on the EHR, including current staff and new hires. The task is achievable when providing the nursing staff with education provided by the informatics staff. The plan is realistic because time and resources are committed by...
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...Personal Health Record (PHRs) Nursing Informatics Oluwatoyin Abolarin Dr. Randolph Schild 11/30/2014 ABSTRACT The purpose of this paper is to generate information in regards to Personal Health Records (PHRs) in relation to the nursing profession. The emergence of PHRs came to light as a collective result of our complex set of medical needs, increasing need for timely access to health information’s without jeopardizing our privacy rights as patients, increasing advancement in technologies and pressure to reduce cost of effectively healthcare delivery. I will be providing different definitions of PHRs, types and general features. I will support my definitions will existing literatures to show how close it is in meaning and features to Electronic Health Records (EHR) as literature has shown preference for PHRs that are tethered to EHR. PHRs have several benefits and barriers with more emerging as new studies are being generated. This paper will also look at ways nurses can contribute to PHRs through the use of standardized nursing language and home education information’s searchable on the PHRs. I will be using online database searches through CINAHL, MEDLINE to support this review. INTRODUCTION Access to the internet has dramatically grown over the years thereby awarding a huge strength to the capacity of the internet to expand health care delivery. Research has shown that, “seeking information related to the users’ health concerns, including disease, disease management, medications...
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...Electronic health records (EHR) are the central database for all patient related data, both clinical and financial for many healthcare organizations. The EHR must have the ability to send and receive data to other systems within and outside the healthcare organization. Standardized terminologies in and EHR makes the sharing of data or interoperability possible. Having a common interface design, such as health level-7 (HL7) allow this to happen. (McGonigle & Mastrian, 2015). Standard terms that describe health conditions, labs, and medications further allow for the transfer of data. At my organization we transmit continuity of care documents or CCD that allows for our data to flow into our community physicians EHR. There are also nursing...
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